The Rationalization of Psychotherapy

THE RATIONALIZATION OF PSYCHOTHERAPY RICHARD C. U'REN* For the German sociologist Max Weber, the basic characteristic of the Western way of life is rationalization. Broadly defined, rationalization means the progressive application of reason to human endeavor. In Weber's writings, however, formal rationalization is defined more narrowly and refers to a variety ofrelated processes in which individual and social behavior become progressively subject to calculability, measurement , and control [I]. It is "the process by which explicit, abstract, intellectually calculable rules and procedures are increasingly substituted for sentiment, tradition, and rule-of-thumb in all spheres of activity" [2, p. 26]. To Weber, the implications of the spread of formal rationality were very great. He foresaw a world increasingly dominated by bureaucracy and technology in which organizational structures would be designed in compliance with administrative and technological imperatives, not in accordance with human needs. Weber envisaged, feared even, an overorganized society—an "iron cage" [3, p. 181]—increasingly objective, efficient, calculating, and dehumanizing. Weber himself never discussed medicine as a separate sphere of societal activity, as he did law and religion, nor did he touch on psychiatry or psychotherapy, which were in any case still in their adolescence at the time of his death in 1920. But Weber's moral stance, concerned as it was with the fate of individuals in a capitalist civilization, invites consideration of the practice of psychotherapy and how it fits into a rationalized world, one less and less capable, in Weber's view, ofallowing for individual autonomy and freedom. Characterizations of psychotherapy are difficult because the field is so vast. Nevertheless, most forms of psychotherapy are inspired by a humanistic impulse to help people and at least have the potential to free ?Department of Psychiatry, Oregon Health Sciences University, 3181 Southwest Sam Jackson Park Road, Portland, Oregon 97201.© 1987 by The University of Chicago. All rights reserved. 0031-5982/87/3004-0537$01.00 586 J Richard C. U'Ren ¦ Rationalization ofPsychotherapy individuals in some way, whether it be by helping them to understand the past and its relevance to the present, by reducing symptoms, or by promoting simple emotional catharsis. How the psychotherapies actually work is controversial. Debate continues about whether specific factors (such as the technique) or nonspecific factors (such as the interpersonal relationship) account for a positive result [4]. Except for a few well-defined problems that are amenable to behavior therapy, evidence for the efficacy of specific techniques in the treatment of most psychiatric problems has not been very impressive . Less well-defined ("nonspecific") factors have been invoked as responsible for the success of psychotherapy [5]. These include an intense, personal, emotionally charged relationship, a setting that contains symbols of healing, a rationale or myth that provides an explanation of the patient's distress and a method for relieving it, the ability to arouse expectations of help, and the facilitation of emotional arousal. Research has also documented the importance of the therapist's personality in the outcome of treatment [6, pp. 299-344]. In other words, aspects of psychotherapy that are not easily quantifiable or standardizable, that are not technique centered or instrumental, seem to play a critical role in the psychotherapeutic enterprise. This state ofaffairs is not pleasing to critics, who are annoyed with the inexactness ofthe field, a field that has not been sufficiently objectified to satisfy the canons of science [7]. The demand that psychotherapy be more scientific means the development of standard, empirically proved, replicable techniques that can be applied in a calculable fashion to clearly defined problems with a specified outcome. This represents, for Weber, rationalization in its practical and formal aspects. Several ironies lie behind the insistent demand of the critics, however. The first is that medicine has already been heavily criticized for being too technologically oriented. It is as if medicine is already too technical and psychiatry (and psychotherapy) not enough so. The second irony is that to the extent that psychotherapy techniques become more standardized , the higher the risk will be that personal, subjective, spontaneous, and even idiosyncratic aspects of psychotherapy that play a large role in the healing process may be overlooked if not eliminated. The third irony associated with this demand...